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Based on record review and interviews with hospital staff, the governing body does not ensure quality care is provided to patients by ensuring adequate and properly trained staff and needed facilities are available to care for the types of patients cared for in the hospital. Bariatric procedures are performed at the hospital and there was no evidence that hospital staff had been trained to take care of these specialized patients and that the hospital has the appropriate facilities to assure optimum care for these specialized patients.

Findings:

1. On the morning of 01/06/2010, administrative staff told the surveyors that they had 15-bed units on floors 2, 3 and 4 and they were medical/surgical units. They stated that only the second and third floor were utilized. They stated that if the census was, or expected to remain, 15 or below, they would only staff the second floor. They confirmed the hospital did not have a designated intensive care unit (ICU).

2. Seven registered nurses' personnel files reviewed, who worked surgery, ER or house supervisor, did not demonstrate the nurses had been determined qualified to work/provide ICU care. The training did not demonstrate the nurses were proficient in providing specialized care required of post-operative gastric patients to recognize complications and bleeds.

3. Review of the credential file of physician ( # 2 ), who performs bariatric surgeries, did not have evidence of a current appointment to the hospital's medical staff. The physician was given temporary privileges previously, but those had expired in November 2009. There was also no evidence in the file of a current DEA (Drug Enforcement Agency) narcotic permit.

4. Two ( December 10 and 11, 2009 ) of the three days when the third floor Medical/Surgical Unit was opened for patient care there was not a registered nurse assigned to this unit.

Based on a review of policies and procedures, complaint/grievance reports, and a staff interview, the hospital failed to ensure a patient grievance resolution included a written notice of its decision. In four of five complaint/grievance reports (Grievance A, B, C, D), there was no closure or resolution and no written notices or letters were sent.

Findings:

1. Grievances A, B, and D were written grievances by patients after they were discharged. There was no documentation of resolutions or letters written and sent.

2. Grievance C was a written grievance by the patient after being discharged. The staff person in charge of grievances (social services) forwarded this grievance to another staff member for resolution. There was no documentation of a resolution or letter being written and sent to the complainant.

3. During an interview with the social service person in the morning of January 6, 2010, she stated "I never write letters."

Based on review of files at the Department, hospital documents and interviews with hospital staff, the hospital failed to provide care in a safe setting to one of five patients, whose medical records were reviewed.

Findings:

1. According to documents filed with the Department, the hospital is licensed for 45 medical/surgical beds and does not have any specialty units.

2. Upon arrival on the morning of 01/06/2010, administrative staff told the surveyors that they had 15-bed units on floors 2, 3 and 4 and they were medical/surgical units. They stated that only the second and third floors were utilized. They stated that if the census was, or expected to remain, 15 or below, they would only staff the second floor. They confirmed the hospital did not have an intensive care unit (ICU).

3. The hospital's policy for " Plan for the Provision of Patient Care", with an implementation date of March 16, 2009, stipulated, on page 8 #C, that " Postoperative recovery is done in the Post Anesthesia Care Unit " (PACU) and that the unit would remain open "until the last case of the day is safely recovered". According to the policy, the surgical area has both Phase I and Phase II recovery. The hospital did not follow its policy. Patient #1 was not completely recovered in the PACU. The patient was not hemodynamically stable when he was transferred to the emergency room (ER). The patient was placed on neosynephrine drip, dopamine drip, Normosol at 1000cc/hr and then transferred to the ER with a blood pressure "in the 50's". (See Finding #7 for reason provided to the surveyors for transfer/transport to ER.)

4. The hospital's policy for "Plan for the Provision of Patient Care", with an implementation date of March 16, 2009, stipulated, on page 8#C, the "An anesthesiologist remains in the facility and available to see the patient if there are any postoperative anesthesia complications during the immediate recovery period, while the patient is in PACU or phase II Recovery". The hospital did not follow its policy. There is no documentation to support the anesthesiologist being in the building during the time of Patient #1's postoperative complications. The patient was hemodynamically unstable with blood pressures in the 50's while on Neosynephrine drip, Dopamine drip and Normosol at 1000 cc/hr.

5. On 12/11/2009, Patient #1 was admitted for emergency gastric repair. The patient had a Roux-en Y gastric bypass in 2003. The patient was held in PACU approximately 2 ? hours, from 0112 until 0350 on 12/12/2009. The patient arrived in the PACU on a Neosynephrine drip at 40 micrograms per minute. An attempt was made to take the patient off the Neosynephrine drip at 0150. At 0233, the patient was again placed on Neosynephrine drip at 20 micrograms per minute due to a blood pressure (B/P) of 69/46. At 0300, the patient ' s B/P was 75/46 and the Neosynephrine was increased to 40 micrograms per minute. At 0320, the nurse documented, " B/P in the 50 ' s " and an order was received from Dr. Gorospe to start a Dopamine drip at 10 micrograms per minute. At 0350, the PACU nurse charted, " B/P remains in the 50 ' s ". At the time the patient left the PACU, at 0350, the patient continued on Normosol at 1000 cc per hour, Neosynephrine drip at 40 micrograms per minute and Dopamine drip at 10 micrograms per minute. The PACU nurse recorded the patient was transferred/transported to the emergency room (ER) for continued care. (See Finding #7 for reason provided to the surveyors for transfer/transport.)

6. The hospital could not produce documentation detailing the care/monitoring provided in the ER so determination of appropriateness of care could not be determined. According to a handwritten note faxed to the surveyors on 01/07/2010, while in the ER, the patient (pt) was administered the following therapies: "Dr. T. intubated patient between 4:15 a.m.-4:30 a.m., Levo going at 0500; Dopamine mcg (milligrams); 3 liters saline; Hetastarch, Neo at 100 - 1st was going when I got here at 5a.m.; 2nd Neo 0540; CPR (cardiopulmonary resuscitation) was started at 0521 by (staff name); pt was given EPI (at) 0421 finished 0522; Atropine given (at) 0522 finished (at) 0523"; pt had a pulse and CPR stopped at 0524; 8units of blood between 0523 and 0625; "3 Albumin at 0556, 1 more Albumin was given at 0601 for a total of 4; pt had 4 liters of saline hanging; 3 amps (ampules) of bicarb were given at 0546 finished 0547; at 0542 Dr. T put in a central line in lt (left) groin; also central line in rt (right) groin in place by Dr. T"; 6 amps bicarb were administered between 0548 to 0607 (all total 9 amps of bicarbonate); "1 gram calcium chloride (at) 0551; Vitamin K given in lt. upper arm at 0615"; 1 more normal saline was hung at 0611 for a total of 5; (and) 2 FFP (fresh frozen plasma) were hung at 0634".

7. The patient's condition continued to deteriorate (as per interview with the Director of Surgery) and at 0650 on 12/12/2009, Patient #1 was taken back for a second surgery. The surgeon documented on his second operative report that he removed 5000 cc. of clotted and unclotted blood from the patient's abdomen. At the end of the second surgery, the patient remained "shocky" and was transferred directly from the OR to another acute care hospital. The patient died that same day.

8. On 01/06/2010 at 1500, the Director of Surgery told the surveyors that Patient #1 could not remain in PACU any longer as her staff had "been at the hospital for 23 hours straight so needed to go home (and) so the patient was taken to the ER". She indicated this situation had not occurred before. The Director of Surgery indicated the patient was taken to the ER because the hospital does not have an ICU unit with appropriately trained staff. She stated the PACU and ER nurses were "deemed capable" of providing ICU level care. Administrative staff did not identify what "deemed" capable meant.

9. The hospital did not have a written protocol/established plan for providing care for critical patients who needed continued intensive nursing care after the recovery room. The hospital's policy for " Plan for the Provision of Patient Care", with an implementation date of March 16, 2009, on page 11 #H, stipulated under the ER section, "A patient whose condition requires treatment/services beyond facility scope are stabilized, and then transferred to an appropriate facility for further assessment and treatment." The facility did not follow it's policy. Patient #1 required ICU level care; this level of care is not within the scope of services available at the hospital. Necessity for this level of care is also evidenced by the "transfer consent" provided to the hospital surveyors on 01/07/2010 the benefits of transfer stated "ICU, Cardiac and pulmonary consultant".


10. On 01/06/2010 at 1500, the Director of Surgery told the surveyors that this type of surgery had never been scheduled at the hospital, but that the same surgeon planned to start doing gastric bypass surgeries at the hospital. Seven registered nurses' personnel files reviewed, who worked surgery, ER or house supervisor, did not demonstrate the nurses had prior training or experience in ICU or with bariatric patient care. The records provided did not contain evidence the nurses had received training on providing the specialized care required of post-operative gastric patients, including signs and symptoms for early recognition of complications and post-operative bleeds.


11. The staff designated for the ER for the shift 7 PM to 7 AM was one RN and one orienting RN according to the Director of Nursing and the staffing sheet provided for review.


12. Review of staffing sheets provided and documentation provided after the survey the RN (the house supervisor) assigned to patients on the third floor on December 12, 2009 during the 7 PM to 7 AM shift was in the ER during the Code Blue event. The only person left with patients on the third floor was an unlicensed aide. Oklahoma Licensure Requirement 310:667-15-3 (c) "if a licensed practical nurse or nurse aide is assigned care of patients who do not generally need skilled nursing care, there shall be a registered nurse supervisor who makes frequent rounds and is immediately available to give skilled nursing care when needed. This registered nurse shall be free to render bedside care and not be occupied in the operating room, delivery room or emergency room for long periods of time."


On the afternoon of 01/06/2010, administrative staff told the surveyors that hospital staff held a meeting the day after the incident concerning events at the hospital on 12/12/2009 and involving Patient #1. It was understood by surveyors that due to the necessity of lack of PACU staff to monitor Patient #1, the patient was taken to the ER and due to the critical nature/condition of the patient, the house supervisor, who was assigned to care for patients on the third floor, also came to the ER to help with Patient #1.

The hospital investigation/debriefing documentation, handwritten by administrative staff, was supplied with Patient #1's medical record. The handwritten notes recorded " patient unattended." The documentation did not specify what patient was unattended, where it occurred or for what length of time.

The surgeon who performed surgery on Patient #1 did not have current privileges at the hospital. Review of the credential file of physician ( # 2 ), who performs bariatric surgeries, did not have evidence of a current appointment to the hospital's medical staff. The physician was given temporary privileges previously, but those had expired in November 2009. There was also no evidence in the file of a current DEA (Drug Enforcement Agency) narcotic permit.

Based on the review of abuse and neglect policies and procedures and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital provided three policies for review. The policies concerned child abuse, elder abuse, sexual abuse and spousal/domestic abuse concerning patients who present to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Interviews with hospital staff on 01/06/10 in the afternoon verified that the hospital does not have a written policy that includes the required elements for effective abuse protection.

Based on a review of policies and procedures, medical/surgical assignment sheets, a staffing sheet, staffing matrix, observation, and staff interviews, the hospital failed to ensure there were sufficient numbers of registered nurses to provide each unit with the immediate availability of an RN for bedside care. Two of the three days when the third floor Medical/Surgical Unit was opened for patient care there was not a registered nurse assigned to this unit.

Findings:

1. Administrative staff told the surveyors that nursing staff worked 12-hour shifts (7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.). Surveyor requested nursing staffing and census for the time period of December 6 through 19, 2009. At first the Director of Nursing stated and documented there were no patients on the third floor. When asked if this census was correct, she took the sheet and returned with a staffing sheet documenting there were patients on the third floor for the 24-hour period on December 9, 10 and 11, 2009.

2. On December 10 and 11, 2009, the third floor day shifts did not have a registered nurse assigned to this area. On December 10 the patient census on the third floor documented five patients and on December 11 there were three patients. During an afternoon interview with the director of nursing on January 6, 2010, the director stated on these days the registered nurse on the second floor covered both the second and third floors.

3. The policy and procedure titled "Plan for the Provision of Patient Care, P. Medical/Surgical Patient Care Unit, page 17, Staffing Requirements," states: The Medical/Surgical Unit is staffed with a Registered Nurse 24 hours per day, 7 days per week.
On December 10, and 11, 2009, the hospital had two medical/surgical units open with patients - one on second floor and one on third flood. Each unit/floor was not staffed with a RN. Oklahoma Licensure 310:667-15-3(a) There shall be an adequate number of registered nurses to meet the following minimum staff requirements: director of the department; assistants to the director for evening and night services; supervisory and staff personnel for each department or nursing unit to insure the immediate availability of a registered nurse for bedside care of any patient when needed; and registered nurse on duty at all times and available on-site for all patients on a twenty-four (24) hour basis.

4. Hospital investigation/debriefing documentation supplied with Patient #1 ' s medical record recorded " patient unattended. " The documentation did not specify what patient was unattended, where it occurred or for what length of time.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients with special and complex needs have nurses assigned that have the specialized qualifications needed to care for these patients. The hospital is performing bariatric surgery on patients and there is no evidence hospital's nursing staff has specialized training to take care of these types of patients. Seven of eight registered nurses' ( RN ) personnel files reviewed did not have evidence of specialized training in critical care nursing.

Findings:

1. Oklahoma Licensure requirement 310:667-15-7 Special Care Units (e) "all nursing personnel shall be prepared for their responsibilities in the special care unit through orientation, ongoing inservice training, and continuing education programs. A planned, formal training program shall be required for registered nurses and licensed practical nurses and shall be of sufficient duration and substance to cover applicable patient care responsibilities in the special-care unit".

2. Seven registered nurses' personnel files reviewed, who worked surgery, ER or house supervisor, did not demonstrate the nurses had been determined qualified to work/provide ICU care. The training did not demonstrate the nurses were proficient in providing specialized care required of post-operative gastric bypass patients to recognize complications and bleeds.

2. The Director of Nursing on 01/06/2010 at 1500 told the surveyors Patient #1 could not remain in PACU any longer as her staff had "been at the hospital for 23 hours straight so needed to go home (and) so the patient was taken to the ER". The hospital does not have an ICU unit with appropriately trained staff. She stated the PACU and ER nurses were "deemed capable" of providing ICU level care.

Based on record reviews and interviews with hospital staff, the hospital does not ensure that medical records are complete, retained and properly filed for prompt retrieval. This occurred for one of five medical records reviewed.

Findings:

1. Administrative staff told the surveyors that all patient medical records were maintained on computer/electronic medical records. The surveyors requested eight patient medical records and reviewed five.

2. At the time the records were provided to the surveyors on 01/06/2010, medical records staff told the surveyors that the medical records had been printed and were complete.

3. At the time of review of Patient #1 medical record on the afternoon of 01/06/2010, the medical record did not contain:
a. Physician orders for laboratory and postoperative care and medications. The record only contained a faxed admission order.

b. Anesthesia documentation for either surgery. (The patient underwent two separate surgeries.)

c. The record did not document when either surgery ended or when the patient was transferred to another acute care hospital and in what condition.

d. On the afternoon of 01/06/2010, the Director of Surgery told the surveyors that the patient received multiple units of blood. The medical record did not contain a signed consent for the blood from the patient or authorized representative. The record did not contain orders or blood administration records for the blood.

e. On 01/06/2010 at 1500, the Director of Surgery told the surveyors that after the first surgery and after a limited time in recovery room (PACU), Patient #1 could not remain in PACU any longer as her staff had "been at the hospital for 23 hours straight so needed to go home (and) so the patient was taken to the ER". Hospital staff reported the patient was kept and monitored in the ER after PACU, but no record of this was provided for review.

f. On 01/06/2010 at 1530, the Director of Surgery told the surveyors that the patient required emergency cardiopulmonary resuscitation (CPR/Code Blue) while in the ER and before the patient was transferred back to surgery. The medical record did not have the details of the CPR event and who was present.

g. On the afternoon of 01/06/2010, IT (Information Technology) staff supplied the data via computer and agreed there was no additional data to be obtained other than what was in the printed record.


4. On January 7, 2010, the Director of Quality called one surveyor stating she had found the missing portions of the patient's medical record and wanted to fax it to the Department. The material sent still did not contain physician orders for care and medications, anesthesia reports for the second surgery, or nursing notes for the care provided in the ER.


5. After receipt of the first documents on 01/07/2010 were reviewed and deficiencies, the decision was made to request the entire/complete medical record from the facility. One surveyor called and requested the hospital send the entire medical record for patient #1. This record was logged in as received on January 8, 2010. The medical record was still not complete.

a. The medical record provided for review did not contain Patient #1's responses to medications and services after being transferred to the ER from PACU after having a surgical procedure. The medical record for Patient #1 did not contain nursing documentation, vital signs and medications in the time period from 0350 on 12/12/09 when the patient was transferred to the ER until approximately 0500 on 12/12/09.

b. The only documentation in Patient #1's record during the patients stay in the ER was a handwritten sheet of paper documenting medications and blood that had been administered from the time period 0500 to 0634 on 12/12/09. Patient #1 was transferred back to surgery at approximately 0656 on 12/12/09. This handwritten documentation did not identify the author of this documentation.

c. The medical record sent on January 8, 2010 as the entire record still did not contain the details of the CPR event and who was present.

d. The record did not contain transfer paperwork with documentation of acceptance from the receiving hospital.

Based on record review and interviews with hospital staff, the hospital does not ensure that the medical record provided for review contains information describing the patients condition, progress and responses to treatment. The medical record provided for review did not contain Patient #1's responses to medications and services after being transferred to the ER from PACU after having a surgical procedure.

Findings:

1. The medical record for Patient #1 did not contain nursing documentation, vital signs and medications in the time period from 0350 on 12/12/09 when the patient was transferred to the ER until approximately 0500 on 12/12/09.

2. The only documentation in Patient #1's record during the patients stay in the ER was a handwritten sheet of paper documenting medications and blood that had been administered from the time period 0500 to 0634 on 12/12/09. Patient #1 was transferred back to surgery at approximately 0656 on 12/12/09. This handwritten documentation did not identify the author.

3. Hospital staff in the afternoon of 01/06/10 stated that Patient #1 had needed CPR and that this was performed while the patient was in the ER and before the patient was transferred back to surgery. The medical record did not have the details of the CPR event and who was present.

Based on record review and interviews with hospital staff, the hospital does not ensure that performance improvement activities track and analyze medical errors and adverse events. Review of the occurrence reports for October and November 2009 which include falls and medication errors and performance improvement meeting minutes from 2009 and 2010 did not have evidence that these occurances were analyzed to determine probable cause and implement preventive actions. Four days of occurance reports in October and November 2009 had numbers of occurances ranging from 15 per day to 23 per day. No evidence was presented to show these were analyzed and action taken. This was confirmed upon interview with staff on the afternoon of 01/06/10.